Human iPS cell-derived astrocyte transplants preserve ...docs.house.gov/meetings/IF/IF04/20160302/104605/HHRG-114-IF04...Research Paper Human iPS cell-derived astrocyte transplants

Experimental Neurology 271 (2015) 479–492

Contents lists available at ScienceDirect

Experimental Neurology

j ourna l homepage: www.e lsev ie r .com/ locate /yexnr

Research Paper

Human iPS cell-derived astrocyte transplants preserve respiratoryfunction after spinal cord injury

Ke Li a, Elham Javed a, Daniel Scura a, Tamara J. Hala a, Suneil Seetharam a, Aditi Falnikar a,Jean-Philippe Richard b, Ashley Chorath a, Nicholas J. Maragakis b, Megan C. Wright c, Angelo C. Lepore a,⁎a Department of Neuroscience, Farber Institute for Neurosciences, Sidney KimmelMedical College at Thomas Jefferson University, 900Walnut Street, JHN 469, Philadelphia, PA 19107, United Statesb Department of Neurology, Johns Hopkins University School of Medicine, 855N. Wolfe St., Rangos 250, Baltimore, MD 21205, United Statesc Department of Biology, Arcadia University, 450S. Easton Rd., 220 Boyer Hall, Glenside, PA 19038, United States

Abbreviations: SCI, spinal cord injury; iPS cells, inducedhuman induced pluripotent stem cell-derived astrocytes;PhMN, phrenic motor neuron; C3 (4 5, etc.), cervical spinglial-restricted precursor; CMAP, compoundmuscle actionjunction; GFP–hIPSA, lentivirus-GFP transduced hIPSAtransduced hIPSA; GFP–hFibro, lentivirus-GFP transducedtivirus-GFP; LV-GLT1, lentivirus-GLT1.⁎ Corresponding author.

E-mail addresses: [email protected] (K. Li), [email protected] (D. Scura), [email protected]@jefferson.edu (S. Seetharam), [email protected] (J.-P. Richard), Ashley.chorath@[email protected] (N.J. Maragakis), [email protected]@jefferson.edu (A.C. Lepore).

http://dx.doi.org/10.1016/j.expneurol.2015.07.0200014-4886/© 2015 Elsevier Inc. All rights reserved.

a b s t r a c t

Article history:Received 5 June 2015Received in revised form 14 July 2015Accepted 21 July 2015Available online 26 July 2015

Keywords:Induced pluripotent stem cellsCervical spinal cord contusionAstrocyteGlutamate transporterGlial progenitor

Transplantation-based replacement of lost and/or dysfunctional astrocytes is a promising therapy for spinal cordinjury (SCI) that has not been extensively explored, despite the integral roles played by astrocytes in the centralnervous system (CNS). Induced pluripotent stem (iPS) cells are a clinically-relevant source of pluripotent cellsthat both avoid ethical issues of embryonic stem cells and allow for homogeneous derivation of mature celltypes in large quantities, potentially in an autologous fashion. Despite their promise, the iPS cell field is in itsinfancy with respect to evaluating in vivo graft integration and therapeutic efficacy in SCI models. Astrocytes ex-press the major glutamate transporter, GLT1, which is responsible for the vast majority of glutamate uptake inspinal cord. Following SCI, compromised GLT1 expression/function can increase susceptibility to excitotoxicity.We therefore evaluated intraspinal transplantation of human iPS cell-derived astrocytes (hIPSAs) followingcervical contusion SCI as a novel strategy for reconstituting GLT1 expression and for protecting diaphragmaticrespiratory neural circuitry. Transplant-derived cells showed robust long-term survival post-injection and effi-ciently differentiated into astrocytes in injured spinal cord of both immunesuppressed mice and rats. However,the majority of transplant-derived astrocytes did not express high levels of GLT1, particularly at early timespost-injection. To enhance their ability to modulate extracellular glutamate levels, we engineered hIPSAs withlentivirus to constitutively express GLT1. Overexpression significantly increased GLT1 protein and functionalGLT1-mediated glutamate uptake levels in hIPSAs both in vitro and in vivo post-transplantation. Compared tohuman fibroblast control and unmodified hIPSA transplantation, GLT1-overexpressing hIPSAs reduced (1) lesionsizewithin the injured cervical spinal cord, (2)morphological denervation by respiratory phrenicmotor neuronsat the diaphragm neuromuscular junction, and (3) functional diaphragm denervation as measured by recordingof spontaneous EMGs and evoked compound muscle action potentials. Our findings demonstrate that hiPSAtransplantation is a therapeutically-powerful approach for SCI.

© 2015 Elsevier Inc. All rights reserved.

pluripotent stem cells; hIPSAs,GLT1, glutamate transporter 1;al cord level 3 (4, 5, etc.); GRP,potential; NMJ, neuromuscular; GLT1–hIPSA, lentivirus-GLT1human fibroblast; LV-GFP, len-

[email protected] (E. Javed),son.edu (T.J. Hala),[email protected] (A. Falnikar),n.edu (A. Chorath),(M.C. Wright),

1. Introduction

Transplantation of neural stem cells (NSCs) and neural progenitorcells (NPCs) is a promising therapeutic strategy for both neurodegener-ative diseases of the central nervous system (CNS) and traumatic CNSinjury, including spinal cord injury (SCI), because of the ability toreplace lost and/or dysfunctional nervous system cell types, promoteneuroprotection, deliver gene factors of interest and provide otherbenefits (Gage, 2000).

Initial trauma following SCI results in immediate cell death andaxotomy of passing fibers. Contusion- and compression-type injuries,the predominant forms of traumatic SCI observed in the clinical popula-tion, are followed by an extended period of secondary cell death andconsequent exacerbation of functional deficits (McDonald and Becker,

480 K. Li et al. / Experimental Neurology 271 (2015) 479–492

2003). One of themajor causes of secondary degeneration following SCIis excitotoxic cell death due to dysregulation of extracellular glutamatehomeostasis (Park et al., 2004; Stys, 2004). Exogenous parenchymal ad-ministration of glutamate to uninjured spinal cord results in tissue andfunction loss similar to SCI (Xu et al., 2005).While large increases in glu-tamate can occur shortly after SCI, elevation can also persist dependingon injury severity (Liu et al., 1991; Panter et al., 1990; Xu et al., 2004). Inaddition to focal increases, levels can also rise in regions removed fromthe lesion site, possibly via a spreading mechanism involving activatedglia (Hulsebosch, 2008). Early gray matter loss is likely mediated byNMDA receptors, while delayed loss of neurons and oligodendrocytes,aswell as axonal andmyelin injury, is thought to be predominantlyme-diated via AMPA over-activation (Stys, 2004). A valuable opportunitytherefore exists after SCI for preventing cell injury and functional lossthat occur during secondary degeneration. Importantly, secondary de-generation is a relevant therapeutic target given its relatively prolongedtime window.

Glutamate is efficiently cleared from the synapse and other sitesby transporters located on the plasma membrane (Maragakis andRothstein, 2004). Astrocytes are supportive glial cells that play a hostof crucial roles in CNS function (Pekny and Nilsson, 2005). Astrocytesexpress the major CNS glutamate transporter, GLT1, which is responsi-ble for the vast majority of functional glutamate uptake and plays acentral role in regulation of extracellular glutamate homeostasis in thespinal cord (Maragakis and Rothstein, 2006). Following SCI, astrocyteloss and/or altered GLT1 expression, function and localization can resultin further susceptibility to excitotoxicity. For example, we previouslyfound that in rodent models of unilateral mid-cervical (C4) contusionSCI, numbers of GLT1-expressing astrocytes, total intraspinal GLT1protein expression and GLT1-mediated functional glutamate uptake inventral horn are reduced soon after injury and this reduction persistschronically (Li et al., 2015). Astrocytes have traditionally been viewedin a negative light following CNS trauma because of their associationwith disease mechanisms such as glial scarring and pro-inflammatorycytokine release. However, their crucial neuroprotective/homeostaticroles, including GLT1-mediated glutamate uptake, have not been exten-sively targeted in SCI models using approaches such as NSC and NPCtransplantation, despite obvious therapeutic implications (Maragakisand Rothstein, 2006).

Transplantation-based targeting of astrocytes provides a number ofkey benefits. Grafts can be anatomically delivered to precise locationsfor achieving neuroprotection of specific populations of cells (Leporeet al., 2008b). Alternative strategies such as gene therapy only targetone/several specific genes (s), while astrocyte transplantation can par-ticipate in the restoration of a host of astrocyte functions. Transplanta-tion also provides for long-term astrocyte integration and therapeuticreplacement. For example, the lasting nature of dysregulation of extra-cellular glutamate homeostasis after SCI (Lepore et al., 2011a,2011c)calls for longer-term maintenance of therapeutic effects, both with re-spect to early cell loss occurring during secondary degeneration andoutcomes of SCI associated with more persistent pathophysiology ofglutamate signaling such as chronic neuropathic pain (Gwak et al.,2012; Hulsebosch, 2008).

To achieve translation of NSC/NPC-based interventions,clinically-relevant cell sources that address scientific, practical andethical considerations must be extensively tested in relevant modelsof CNS disease. These cell types also need to be evaluated in the con-text of patient-relevant functional outcomes such as respiratoryfunction. Induced pluripotent stem (iPS) cells are pluripotent cellsgenerated from adult somatic cell types via expression of combina-tions of pluripotency-related factors, avoiding ethical issues of embry-onic stem cells (Takahashi et al., 2007b). This technology allows forhomogeneous derivation of cell types in large quantities for applicationssuch as transplantation, potentially in an autologous fashion from theeventual recipient or from allogeneic sources (Das and Pal, 2010;Kiskinis and Eggan, 2010). Despite the promise of this approach, the

iPS cell transplantation field is still in the early stages of evaluatingtherapeutic usefulness in relevant SCI models (Salewski et al., 2010).

Respiratory compromise is amajor problem following cervical spinalcord trauma. Cervical SCI represents greater than half of all humancases, in addition to often resulting in themost severe physical and psy-chological debilitation (Lane et al., 2008). Respiratory compromise isthe leading cause of morbidity and mortality following SCI. While agrowing literature exists on respiratory function in animal models ofSCI (Lane et al., 2008, 2009), few studies have examined cellular mech-anisms involved in protection of this vital neural circuitry, and littlework has been conducted to test therapies for targeting cervical spinalcord-related functional outcome measures such as breathing. Phrenicmotor neuron (PhMN) loss plays a central role in respiratory compro-mise following cervical SCI. The diaphragm, a major inspiratory muscle,is innervated by PhMNs located at cervical levels 3–5 (Lane et al., 2009).PhMNoutput is driven by descendingpre-motor bulbospinal neurons inthe medullary rostral ventral respiratory group (rVRG) (Zimmer et al.,2007). Cervical SCI results in diaphragmatic respiratory compromisedue to PhMN loss and/or injury to descending bulbospinal respiratoryaxons. The majority of these injuries affect mid-cervical levels(Shanmuganathan et al., 2008) (the location of the PhMN pool), and re-spiratory function followingmid-cervical SCI is significantly determinedby PhMN loss/sparing (Strakowski et al., 2007). Although use of thoracicmodels has predominated, cervical SCI animal models have recentlybeen developed (Aguilar and Steward, 2010; Awad et al., 2013; Genselet al., 2006; Lane et al., 2012; Lee et al., 2010; Sandrow-Feinberg et al.,2009, 2010; Sandrow et al., 2008; Stamegna et al., 2011), includingour own (Nicaise et al., 2012). Because of the relevance of astrocyteand GLT1 dysfunction to PhMN loss/injury following cervical trauma,we targeted transplantation in the present study to cervical spinalcord ventral horn in a cervical contusion SCI model.

We previously investigated the therapeutic efficacy of transplantingrodent-derived glial-restricted precursors (GRP), a class of lineage-restricted astrocyte progenitor cell (Li et al., 2014). We transplantedeither undifferentiated GRPs or GRP-derived astrocytes (pre-differenti-ated in vitro prior to injection) into our model of cervical contusion SCI,and found that both cell types survived, localized to the ventral hornand efficiently differentiated into mature astrocytes. However, animalsinjected with GRP-derived astrocytes had higher levels of intraspinalGLT1 expression than those injected with undifferentiated GRPs,suggesting that pre-differentiation enhanced the in vivo maturation ofthese cells. We also observed that modifying GRP-derived astrocytesto constitutively express GLT1 was more effective in achieving in vivoGLT1 expression and for protecting PhMNs.

Given the importance of astrocytes in SCI pathogenesis, the observa-tions of GLT1 dysfunction following SCI, and our previous successtargeting astrocyte GLT1 using rodent-derived glial progenitor cells, inthe present study we evaluated intraspinal transplantation of hiPScell-derived astrocytes (hIPSAs) into ventral horn following cervicalcontusion SCI as a novel therapeutic strategy for reconstituting GLT1function. Specifically, we examined the in vivo fate of hIPSAs transplantsin the injured spinal cord of both mouse and rat models of cervicalcontusion SCI, including long-term survival and integration, astrocytedifferentiation, maturation into GLT1-expressing cells and safety. Wealso tested the therapeutic efficacy of hIPSA transplantation for protec-tion of PhMNs and preservation of diaphragm function.

Derivation of cell types from iPS cells represents a relevant approachfor clinical translation; therefore, it is critical to test both the safety andefficacy of these transplants in a patient-relevant SCI model. Important-ly, previous work has shown that human- and rodent-derived versionsof a given stem/progenitor type do not necessarily show similar in vivofate or therapeutic properties in the disease nervous system. For exam-ple, we previously demonstrated that, following transplantation intothe SOD1G93A rodent model of ALS, human glial progenitors cells showmore persistent proliferation, greater migratory capacity, reducedefficiency of astrocyte differentiation, and decreased GLT1 expression

481K. Li et al. / Experimental Neurology 271 (2015) 479–492

compared to their rodent counterparts, which resulted in a lack of ther-apeutic efficacy onlywith the human cells (Lepore et al., 2008b, 2011b).It is therefore important to extend our previous studies with rodent-derived glial progenitors in the cervical contusion SCI model to nowtest human iPS cells.

2. Materials and methods

2.1. Animals

2.1.1. Transplantation into rats and miceFemale Sprague–Dawley rats weighing 250–300 g were purchased

from Taconic Farm (Rockville, MD). Female C57BL/6 wild-type miceweighing 20–30 g were purchased from The Jackson Laboratory (BarHarbor, ME). All animals were housed in a humidity-, temperature-,and light-controlled animal facility with ad libitum access to water andfood. Experimental procedures were approved by the Thomas JeffersonUniversity IACUC and conducted in compliance with ARRIVE (AnimalResearch: Reporting of In Vivo Experiments) guidelines.

2.2. Cervical contusion SCI

2.2.1. Rat SCIRats were anesthetized with ketamine (100 mg/kg), xylazine

(5 mg/kg) and acepromazine (2 mg/kg). The cervical dorsal skin andunderlying muscles were incised. The paravertebral muscles overlyingC3–C5 were removed. Following unilateral laminectomy on the rightside at C3, C4 and C5 levels, rats were subjected to a C4 spinal contusioninjurywith the Infinite Horizon impactor (Precision Systems and Instru-mentation, Lexington, KY) using a 1.5mm tip at a force of 395 kdyn. Thisinjury paradigm is based on our previously published ratmodel that re-sults in robust PhMN degeneration and chronic diaphragm dysfunction(Nicaise et al., 2012, 2013). Rats were transplanted in all studies imme-diately following injury. After surgical procedures, overlying muscleswere closed in layers with sterile 4–0 silk sutures, and the skin incisionwas closed usingwound clips. Animalswere allowed to recover on a cir-culatingwarmwater heatingpad until awake and then returned to theirhome cages. They were monitored daily until sacrifice, and measureswere taken to avoid dehydration and to minimize any pain ordiscomfort.

2.2.2. Mouse SCIMicewere anesthetizedwith a cocktail of ketamine (120mg/kg) and

xylazine (5 mg/kg). The surgical procedure and post-surgical monitor-ing used formicewere the same as described above for rats. For the con-tusion injury, the 1mm impactor tipwas raised 1.25mmabove the duraprior to impact, and a force of 50 kdyn (kdyn) was used for impact.

2.3. Virus production

Lentiviral vector carrying the green fluorescent protein (GFP) geneor GLT1 gene was packaged in 293FT cells. Briefly, to produce controllentiviral-GFP vector, 293FT cells were transfected with pCDH-MSCV-MCS-EF1-GFP plasmid (System Biosciences, Mountain View, CA) andthree other helper plasmids, pLP-1, pLP-2, and pLP/VSVG with Polyfect(Qiagen, Valencia, CA). To produce lentiviral-GLT1 vector, GLT1 geneCDS fragment was inserted into MCS of pCDH-MSCV-MCS-EF1-GFPplasmid, and the vector plasmid was then transfected into 293FT cellswith three helper plasmids as described above. Supernatantwas collect-ed 72 h later, and lentiviral vector was concentrated with PEG-it VirusPrecipitation Solution (System Biosciences, Mountain View, CA) andre-suspended with PBS to the final titer of 1 × 108 infectious units/ml.

2.4. Human induced pluripotent stem cell derived astrocytes

2.4.1. Human iPS cell derivation, culturing and astrocyte differentiationiPS cells were derived from non-diseased healthy patient donors.

Dermal fibroblasts were reprogrammed into iPS cells via retroviraltransduction with KLF4, SOX2, OCT4, and c-MYC (Takahashi et al.,2007a). By immunohistochemistry and qRT-PCR, these putative iPScells expressed proteins and transcripts associated with pluripotency,including Sox 2, and stem cell-associated antigens, including SSEA4,Nanog, alkaline phosphatase, and TRA 1–81, and capacity to differenti-ate into cells of three germ layerswas established. Finally, the karyotypeof these iPS cells was found to be normal. Once pluripotent iPS cellswere generated, the stem cells were cultured in E8 medium (Life Tech-nologies, Grand Island, NY). To maintain optimum pluripotency andlimit spontaneous differentiation, the stem cell colonies were manuallycleaned once every 6 days just before passage using dispase (Stem CellTechnologies, Vancouver, BC). To differentiate the iPS cells into astro-cytes, a protocol previously described by Haidet-Phillips and colleagues(Haidet-Phillips et al., 2014) was used. To summarize, iPS cells werelifted with dispase, gently separated into single cells and plated as amonolayer. Using the smad dual inhibition pathway method to directdifferentiation toward a neural phenotype, the cells were incubated inDMEM/F12 (Life Technologies, Grand Island, NY) enriched with0.2 μM LDN (Stemgent, Cambridge, MA) and 10 μM SB431542 (Sigma,Saint Louis, MO). The cells were then exposed to 1 μM retinoic acid(Sigma, Saint Louis MO) and N2 (Life Technologies, Grand Island, NY)starting at day 5 and Sonic HedgeHog (Life Technologies, Grand Island,NY) starting at day 8. From day 15 to day 30 after starting the differen-tiation protocol, the medium was gradually changed to neurobasalmedium. After day 30, to differentiate these iPS cell-derived glialprogenitors into astrocytes, cells were maintained and expanded inDMEM/F12 supplemented with 1% Fetal Bovine Serum, B27, L-gluta-mine, non-essential amino acids, penicillin/streptomycin (all from LifeTechnologies, Grand Island, NY) and 2 μg/ml Heparin (Sigma-Aldrich,St. Louis, MO) for an additional 60 days. Astrocytes derived fromhuman iPS were identified with immunostaining using GFAP antibody.For feeding and passaging of astrocyte progenitor cultures, cells wererinsed with PBS and incubated with 4 ml of 0.05% trypsin for 5 min.Cells were collected in trypsin and rinsed with 7 ml of culture mediumand 1× trypsin inhibitor (Life Technologies, Grand Island, NY) to stoptrypsinization. Cells were centrifuged at 1000 rpm for 5 min and re-suspended in fresh culture medium. Cells were counted and seededonto poly-L-lysine coated dishes. Cells were fed twice a week andwere passaged after they were 80%–90% confluent.

2.4.2. GLT1 overexpressionAfter differentiation for 90 days, hIPSAs (astrocytes derived from

human iPS cells) were transduced with lentiviral-GFP vector orlentiviral-GLT1 vector, at the concentration of 1 × 106 infectiousunits/ml, one week before transplantation. On the second day oftransduction, culture medium was changed and the cells were cul-tured for 5 more days.

2.5. Human dermal fibroblasts

Human dermal fibroblast cells (ATCC, Manassas, VA) were culturedwith Fibroblast Growth Kit-low serum (ATCC, Manassas, VA). Fibro-blasts were transduced with control lentiviral-GFP vector one week be-fore transplantation. Transduced GFP was used to track transplantedcells in vivo.

2.6. Transplantation

2.6.1. Cell preparation for transplantationOn the day of transplantation, cells were rinsed with PBS and

trypsinized with 0.05% trypsin, collected and rinsed with culture

482 K. Li et al. / Experimental Neurology 271 (2015) 479–492

medium and 1× trypsin inhibitor. The cells were washed with artificialcerebrospinal fluid twice. Cell viability was assessed using the trypanblue assay and was always found to be greater than 80%. The final cellconcentration was adjusted to 1 × 108 cells/ml.

2.6.2. Intraspinal transplantationTransplantation was conducted on deeply anesthetized rats and

mice immediately post-injury. Following unilateral right-sided contu-sion injury at C4, cells were injected into the spinal cord at twolocations. Each site contained 2 μl of cell suspension, which was admin-istered into the spinal cord ventral horn using a Hamilton gas-tight sy-ringe mounted on an electronic UMP3 micropump (World PrecisionInternational, Sarasota, FL) (Lepore and Maragakis, 2011; Lepore et al.,2011a). The sites of injections were located at the rostral and caudaledges of the contusion site. Ventral horns were targeted by loweringthe 33-gauge 45-degree beveled needle 1.5 mm below the dorsal sur-face of the spinal cord. Each injection was delivered at a constant rateover 5 min. Upon completion of cell delivery, overlying muscles werethen closed in layers with sterile 4–0 silk sutures, and the skin incisionwas closed using sterile wound clips. Animals were allowed to recoverand monitored daily.

2.6.3. Immune suppressionAll animals were immune suppressed. Rats received subcutaneous

administration of cyclosporine A (10 mg/kg; Sandoz Pharmaceuticals,East Hanover, NJ) daily beginning three days before grafting andcontinuously until sacrifice. Mice were given both FK-506 andrapamycin (1 mg/kg each; LC Laboratories; Woburn, MA).

2.7. Tissue processing for histology

At the time of sacrifice, animals were anesthetized, and dia-phragmmuscle was freshly removed prior to perfusion and then fur-ther processed for neuromuscular junction (NMJ) labeling. Animalswere transcardially perfused with 0.9% saline, followed by 4%paraformaldehyde infusion. Spinal cords were harvested, thencryoprotected in 30% sucrose for 3 days and embedded in freezingmedium. Spinal cord tissue blocks were cut serially in the sagittalor transverse planes at a thickness of 30 μm. Sections were collectedon glass slides and stored at −20 °C until analysis. Spinal cord sec-tions were thawed, allowed to dry for 1 h at room temperature,and stained with 0.5% Cresyl violet acetate according to standardprocedure (Nicaise et al., 2012).

2.8. Immunohistochemistry

Frozen spinal cord sectionswere air-dried,washedwith PBS, perme-abilized with 0.4% Triton X-100 in PBS for 5 min at room temperature,and then incubated in blocking solution (PBS containing 10% normalgoat serum and 0.4% Triton X-100) for 1 h at room temperature. Sec-tions were labeled overnight at 4 °C with the primary antibodies inblocking solution. Sections were then washed three times with PBS(5 min per wash) and incubated with secondary antibodies in blockingsolution for 1 h at room temperature. After washing twice with PBS(10 min per wash), sections were cover-slipped. A number of primaryantibodies were used. Mouse anti-GFAP antibody (EMD MilliporeCorporation, Billerica, MA; 1:200) and rabbit anti-GFAP antibody(Dako North America, Carpinteria, CA; 1:200) were used to labelastrocytes (Lepore et al., 2008a). Mouse anti-human GFAP antibody(StemCells, Inc, Newark, CA; 1:200) was used to label astrocytes ofhuman origin in mice and rats. Rabbit anti-GLT1 (1:800) and mouseanti-GLT1 (1:200)were used to label GLT1 protein (bothwere providedby Jeffrey Rothstein's laboratory) (Lepore et al., 2008b). Rabbit anti-Ki67(Thermo Fisher Scientific, Rockford, IL; 1:200) labeled proliferating cells(Lepore et al., 2008a). Mouse anti-human cytoplasmic marker antibody(StemCells, Inc, Newark, CA; 1:200) and mouse anti-HuNu antibody

(EMD Millipore Corporation, Billerica, MA; 1:200) were used to labelhuman cytoplasm and human nuclear antigen, respectively, forselectively identifying human-derived cells. Secondary antibodiesincluded: FITC goat-anti-mouse IgG, FITC goat-anti-rabbit IgG, TRITCgoat-anti-mouse IgG, TRITC goat-anti-rabbit IgG, Alexa Fluor 647 goat-anti-mouse IgG, Alexa Fluor 647 goat-anti-rabbit IgG. All secondary an-tibodies (Jackson ImmunoResearch Laboratories, West Grove, PA) werediluted at 1:200 to recognize the matched primary antibody. For fluo-rescence analysis, sections were cover-slipped with fluorescent-compatible mounting medium (ProLong Gold, Life Technologies,Grand Island, NY).

2.9. Quantification of in vitro cultured cell differentiation, proliferation andGLT1 expression

The proportions of GFAP+ astrocytes and Ki67+ proliferating cellswere expressed as a percentage of the total number of cultured cells(labeled by DAPI). In order to quantify double-labeling of DAPI withGFAP or Ki67, images were taken at 10× magnification and analyzedusing ImageJ software. In each image, cells with a DAPI+ nucleus wereassessed for expression of GFAP or Ki67.

2.10. Quantification of transplant differentiation

Rats and mice were sacrificed for quantification of astrocyte differ-entiation (GFAP+) and proliferation (Ki67+). The proportions GFAP+

astrocytes and Ki67+ proliferating cells were expressed as a percentageof the total number of transplanted human cells (labeled by anti-hCytoplasm or HuNu antibody). In order to quantify double-labelingof hCytoplasm or HuNAwith GFAP and Ki67, double-labeled transversesections were imaged at 10×magnification usingMetaMorph softwareand were then analyzed using ImageJ software. In each image, cellsexpressing hCytoplasm or HuNu were assessed for co-expression ofGFAP or Ki67.

2.11. Quantification of GLT1 expression by transplants

Rats and mice were sacrificed for quantification of GLT1 expressionby hCyto-labeled cells in the ventral horn. GLT1+ and hCyto+ cellswere identified in the ventral horn using ImageJ software, and thepercentage of hCyto+ cells (representing any transplant-derived cell)that co-expressed GLT1 were quantified.

2.12. Lesion imaging and quantification

Images were acquired with a Zeiss Imager M2 upright micro-scope and analyzed with ImageJ software. Lesion size was quantifiedin Cresyl violet stained sections (Li et al., 2015). Specifically, lesionarea was determined in every 10th section by tracing both thetotal area of the hemi-spinal cord ipsilateral to the contusion siteand the actual lesion area. Lesion was defined as areas includingboth lost tissue (cystic cavity formation) and surrounding damagedtissue in which the normal anatomical structure of the spinal cordwas lost. The lesion epicenter was defined as the section with thelargest percent lesioned tissue (relative to total tissue area in thesame section).

2.13. Neuromuscular junction (NMJ) analysis

Fresh hemi-diaphragm muscle was dissected from each animalfor whole-mount immunohistochemistry, as described previously(Wright et al., 2007). Hemi-diaphragm muscle was dissected,stretched, pinned down to Sylgard medium (Fisher Scientific, Pitts-burgh, PA), and extensively cleaned to remove any connective tissueto allow for antibody penetration. Motor axons and their terminalswere labeled with SMI-312R (Covance, Princeton, NJ; 1:1000) and

483K. Li et al. / Experimental Neurology 271 (2015) 479–492

SV2-s (DSHB, Iowa City, IA; 1:10), respectively, and both primary an-tibodies were detected with FITC anti-mouse IgG secondary (JacksonImmunoResearch Laboratories, West Grove, PA; 1:100). Post-synaptic acetylcholine receptors were labeled with rhodamine-conjugated alpha-bungarotoxin (Life Technologies, Grand Island,NY; 1:400). Labeled muscles were analyzed for total numbers ofNMJs and intact, denervated and multiply-innervated NMJs.Whole-mounted diaphragms were imaged on a FluoView FV1000confocal microscope (Olympus, Center Valley, PA). We only conduct-ed NMJ analysis in ipsilateral hemi-diaphragm because in our previ-ously publishedworkwe did not observe denervation or sprouting incontralateral hemi-diaphragm after cervical hemi-contusion SCI(Nicaise et al., 2012).

2.14. Functional glutamate uptake assay

After transduction with lentiviral-GFP vector or lentiviral-GLT1 vec-tor, hIPSAs were cultured for 10 days. Human fibroblasts transducedwith lentiviral-GFP vectorwere used as control. Glutamate uptake activ-ity was measured as previously described (Dowd and Robinson, 1996),with slight modification. Briefly, cells were washed and pre-incubatedwith either a sodium- or choline-containing uptake buffer (in mM:Tris, 5; HEPES, 10; NaCl or choline chloride, 140; KCl, 2.5; CaCl2, 1.2;MgCl2, 1.2; K2HPO4, 1.2; glucose, 10) for 20 min at 37 °C; and in DHKtreatment groups, 100 μMofDHKwas added to inhibit GLT1. Theuptakebuffer was then replacedwith fresh uptake buffer containing 20 nM 3H-glutamate (49 Ci/mmol; PerkinElmer, CA) and 20 μM unlabeled gluta-mate. The cells were incubated for 5 min at 37 °C. The reaction was ter-minated by washing cells three times with choline-containing uptakebuffer containing 2 mM unlabeled glutamate, followed by immediatelysis in ice-cold 0.1 N NaOH. Cell extracts were then measured with aliquid scintillation counter (Beckman Instruments, Fullerton, CA). Theprotein content in each well was measured using the Bradford proteinassay (Bio-Rad, Hercules, CA).

2.15. Diaphragm compound muscle action potentials (CMAPs)

Rats were anesthetized in the same manner described above.Phrenic nerve conduction studies were performed with single stim-ulation (0.5 ms duration; 6 mV amplitude) at the neck via nearnerve needle electrodes placed along the phrenic nerve (Li et al.,2015; Nicaise et al., 2012). The ground needle electrode was placedin the tail, and the reference electrode was placed subcutaneouslyin the right abdominal region. Recording was obtained via a surfacestrip along the costal margin of the diaphragm, and CMAP amplitudewas measured baseline to peak. Recordings were made using an ADIPowerlab 8/30 stimulator and BioAMP amplifier (ADInstruments,Colorado Springs, CO), followed by computer-assisted data analysis(Scope 3.5.6, ADInstruments). For each animal, 10–20 tracingswere averaged to ensure reproducibility.

2.16 . Spontaneous EMG recordings

Prior to being euthanized, animals received a laparotomy. TheseEMG recordings were terminal experiments and were only conductedimmediately prior to euthanasia. Bipolar electrodes spaced by 3 mmwere inserted into specific sub-regions of the right hemi-diaphragm(i.e. dorsal, medial or ventral regions) (Li et al., 2015). Activity wasrecorded and averaged during spontaneous breathing at each of these3 locations separately in each animal. The EMG signal was amplified, fil-tered through a band-pass filter (50–3000 Hz), and integrated usingLabChart 7 software (ADInstruments). Parameters such as inspiratorybursts per minute, discharge duration and integrated peak amplitudewere averaged over 2 min sample periods. No attempt was made tocontrol or monitor the overall level of respiratory motor drive duringthe EMG recordings.

2.17. Statistics

Results were expressed as means ± standard error of the mean(SEM). A Kolmogorov–Smirnov test was conducted for all variables toassess normality. Unpaired t test or Mann–Whitney was used to assessstatistical significance between two groups. With respect to multiplecomparisons involving three groups or more, statistical significancewas assessed by analysis of variance (one-way ANOVA) followed bypost-hoc test (Bonferroni's method). Statistics were computed withGraphpad Prism 5 (GraphPad Software, Inc., La Jolla, CA). p b 0.05 wasconsidered as statistically significant.

3. Results

3.1. In vitro characterization of human iPS cell-derived astrocytes (hIPSAs)

We differentiated human iPS cells into astrocytes by culturingthem in differentiating medium containing FBS. We transducedcells with lentivirus (LV)-GFP or LV-GLT1-GFP to generate controlcells (GFP–hIPSAs) and GLT1-overexpressing hIPSAs (GLT1–hIPSAs),respectively. The GFP–hIPSAs expressed little-to-no GLT1 protein(Fig. 1A, C), consistent with the limited expression of GLT1 by cul-tured astrocytes in the absence of neuronal co-culture (Li et al.,2014; Perego et al., 2000), while GLT1–hIPSAs expressed high levelsof GLT1 protein in vitro (Fig. 1B, C). In addition, the vast majority ofDAPI+ GLT1–hIPSAs expressed GLT1 (Fig. 1B), which is expectedgiven the high efficiency of transduction with our lentivirus (notshown). GLT1 overexpression did not alter hiPSA differentiation(Fig. 1D, E, H) or proliferation (Fig. 1F–H). In addition to significantlyincreased GLT1 protein expression levels, GLT1–hIPSAs showed alarge increase in functional GLT1-mediated glutamate uptake com-pared to GFP–hIPSAs using an in vitro 3H-glutamate uptake assay(Fig. 1J). In this 3H-glutamate uptake assay and in the subsequenttransplantation experiments, we used LV-GFP transduced human fi-broblasts (GFP–hFibro) (Fig. 1I) as a non-glial cell control.

3.2. Human iPSA transplants robustly survived and differentiated intoastrocytes following rat cervical contusion SCI

We characterized the fate of transplanted hIPSAs in both rats andmice following unilateral C4 contusion SCI, given the usefulness ofboth experimentalmodels for studying nervous systemdiseases. Imme-diately following injury, we injected hIPSAs directly into the ventralhorn at locations just rostral and caudal to the contusion site (Fig. 2A).We specifically delivered cells into the ventral horn to anatomicallytarget the location of the PhMN pool (Fig. 2B).

We sacrificed rats at 2 days, 2 weeks and 4 weeks post-injury/transplantation. Double-labeling with panGFAP antibody and ahuman-specific GFAP antibody demonstrated that transplantedhuman-derived cells differentiated into astrocytes (Fig. 2C). Bothtransplanted GFP–hIPSAs (Fig. 2D, F, H) and GLT1–hIPSAs (Fig. 2E,G, I) robustly survived out to W4, and nearly all hCytoplasm+

transplant-derived cells co-labeled with the astrocyte lineage marker,GFAP, at D2 (Fig. 2D–E), W2 (Fig. F–G) and W4 (Fig. 2H–I). Therewere no differences in the degree of astrocyte differentiation betweenGFP–hIPSAs and GLT1–hIPSAs at any of these time points (quantifica-tion shown in Fig. 2J). LV-GFP transduced human fibroblasts (GFP–hFibro) also survived in the injured spinal cord to at least W4 post-injury (Fig. 2K).

Despite efficient astrocyte differentiation, only a small percentage ofGFP–hIPSA transplant-derived cells expressed GLT1 protein in the inju-ry site at D2 (Fig. 3A), W2 (Fig. 3C) and W4 (Fig. 3E). On the contrary,the majority of GLT1–hIPSAs robustly expressed GLT1 at all times(Fig. 3B, D, and F) (quantification: Fig. 3G).

Fig. 1. In vitro characterization of human iPS cell-derived astrocytes (hIPSAs). Cells were transduced with lentivirus (LV)-GFP or LV-GLT1–GFP to generate control GFP–hIPSAsand GLT1-overexpressing hIPSAs (GLT1–hIPSAs), respectively. Human cytoplasm+ GFP–hIPSAs expressed little-to-no GLT1 protein (A), while GLT1–hIPSAs expressed highlevels of GLT1 protein in vitro (B), which was further confirmed with immunoblotting analysis (C, lower: quantification result). Following infection with either virus, astrocytedifferentiation was determined by the percentage of cells expressing the astrocyte lineage marker, GFAP (D–E). Proliferation was determined by the percentage of cells express-ing the proliferation marker, Ki67 (F–G). Quantification results of cell differentiation and proliferation are shown in (H). Human fibroblasts, which were transduced with LV-GFPvector (GFP–hFibro) (I), were used as non-glial control in the glutamate uptake assay and in vivo transplantation experiments. 3H-glutamate uptake assay was performed todetect GLT1 function. GLT1–hIPSAs showed a large increase in Na+ dependent glutamate uptake compared to GFP–hFibro and GFP–hIPSAs. This increased uptake was blockedwith GLT1 specific inhibitor, DHK, at the concentration of 100 μmol/l (J). Results were expressed as means ± SEM. *p b 0.05, **p b 0.01. n= 4 per group for GLT1 western blottingquantification analysis; n = 4 per group for cell differentiation and proliferation analysis; n = 4 per group for 3H-glutamate uptake assay.

484 K. Li et al. / Experimental Neurology 271 (2015) 479–492

3.3 . Human iPSA transplants showed limited proliferation in vivo and didnot form tumors

A major concern regarding NSC/NPC therapy (particularly withpluripotent cells such as iPS cells) is the potential for uncontrolledproliferation and even tumor formation. To address this concern,we im-munostained for the proliferation marker, Ki67, and we examinedtransplant recipient rat spinal cords for overt tumor formation. Withboth GFP–hIPSAs (Fig. 4A, C, E) and GLT1–hIPSAs (Fig. 4B, D, F), lessthan 10% of HuNu+ transplant-derived cells expressed Ki67 at D2

(Fig. 4A–B), W2 (Fig. 4C–D) and W4 (Fig. 4E–F) (quantification shownin Fig. 4G). In addition, we never observed tumor formation in anytransplant-recipient animals.

3.4. Human iPSA transplants showed similar survival and differentiation inthe injured mouse cervical spinal cord

Given the usefulness of the mouse model due to the availability oftransgenic tools, we conducted similar characterization of hIPSA fatefollowing transplantation into the mouse spinal cord immediately

Fig. 2.Human iPSA transplants robustly survived, differentiated into astrocytes and localized to the ventral horn following rat cervical contusion SCI. Immediately following unilateral C4contusion SCI, we injected GFP–hIPSAs, GLT1–hIPSAs or GFP–hFibro directly into the ventral horn (VH) at locations just rostral and caudal to the contusion site (A). GFP fluorescence in-dicated that the transplanted hIPSAs were delivered to the ventral horn (B). Double-labeling with pan-GFAP antibody and a human GFAP specific antibody confirmed that all humanGFAP+ cells were also pan-GFAP+ (C). Double immunostaining for pan-GFAP and human cytoplasm marker was performed on spinal cord sections from the GFP–hIPSA (D, F, H) andGLT1–hIPSA (E, G, I) groups at day 2 (D–E), week 2 (F–G) and week 4 (H–I) post-injury/transplantation to quantify astrocyte differentiation by transplanted cells (J). We used LV-GFPtransduced human fibroblasts (GFP–hFibro) as a non-glial cell control (K, inset: high magnification). Results were expressed as means ± SEM. n = 3 per group per time point fortransplanted cell differentiation analysis. Red outlines in panels B and K denote the ventral horn.

485K. Li et al. / Experimental Neurology 271 (2015) 479–492

following unilateral cervical contusion SCI. Similar to transplantationinto the rat SCI model, hIPSAs robustly survived and integrated for atleast 4 weeks post-injection. The majority of transplant-derived cells

were differentiated GFAP+ astrocytes (Fig. 4H). Control GFP–hIPSAsexpressed little GLT1, while overexpression resulted in the majority oftransplant-derived astrocytes expressing GLT1 (Fig. 4I). Less than 10%

Fig. 3. GLT1–hIPSA transplants expresses GLT1 in the ventral horn following rat cervical contusion SCI. Double immunostaining for GLT1 and human cytoplasm was performed on spinalcord sections from the GFP–hIPSA (A, C, E) and GLT1–hIPSA (B, D, F) groups at day 2 (A–B), week 2 (C–D) and week 4 (E–F) post-injury/transplantation to assess GLT1 expression bytransplanted cells in vivo (G). Results were expressed as means ± SEM. ***p b 0.001. n = 3 per group per time point for in vivo GLT1 expression analysis.

486 K. Li et al. / Experimental Neurology 271 (2015) 479–492

of transplant-derived cells continued to proliferate at D2, W2 and W4(Fig. 4J), and again we never observed tumor formation in any mice.

3.5. GLT1 overexpressing hIPSA transplants reduced lesion size followingcervical contusion SCI

To test the therapeutic efficacy of hIPSA transplants in the rat uni-lateral cervical contusion model, we first assessed lesion size. At4 weeks post-injury, we quantified Cresyl-violet stained transversesections of the cervical spinal cord surrounding the injury site forthe degree of ipsilesional tissue sparing by calculating the percent-age of total ipsilateral hemi-cord area comprised of damaged tissue(Fig. 5A). Lesion area (Fig. 5B) and total lesion volume (Fig. 5C) anal-ysis (combined for both white and gray matter) revealed that GLT1–hIPSA transplants significantly reduced lesion size at multiple loca-tions surrounding the epicenter compared to both GFP–hFibro andGFP–hIPSA control transplant groups. We observed this protectiveeffect specifically within 1 mm rostral and caudal of the epicenterwhere the greatest tissue damage occurred.

3.6. GLT1 overexpressing hIPSA transplants preserved diaphragminnervation by phrenic motor neurons after SCI

We found that GLT1 overexpressing hIPSA transplants significantlypreserved morphological innervation at the diaphragm neuromuscularjunction (NMJ), the synapse which is critical for functional PMN–diaphragm connectivity. To examine pathological alterations at thediaphragm NMJ, we analyzed hemi-diaphragm muscle ipsilateral tothe contusion in rats (Fig. 6A–B).We quantified the percentage of intactNMJs or partially denervated NMJs in the animals from the 3 injectiongroups at 4 weeks post-injury/transplantation (Wright et al., 2007,2009; Wright and Son, 2007). For analysis, we divided the hemi-diaphragm into three anatomical regions (ventral, medial and dorsal)(Fig. 6C), as the rostral-caudal axis of the PMN pool within the cervicalspinal cord topographically maps onto the ventral-dorsal axis of thediaphragm (Laskowski and Sanes, 1987). At the dorsal region of thehemi-diaphragm, the percentage of intact NMJs in the GLT1–hIPSAtransplant group was significantly greater than both control groups,while at the ventral and medial regions of the diaphragm, there wereno differences in the percentage of intact NMJs amongst the groups

Fig. 4. TransplantedhiPSAs showed limited proliferation and did not form tumors. Double immunostaining for the proliferationmarker Ki67with human nuclei (HuNu)was performed onspinal cord sections from the GFP–hIPSA (A, C, E) and GLT1–hIPSA (B, D, F) groups at D2 (A–B),W2 (C–D) andW4 (E–F) post-transplantation, and quantification results are shown in (G).Tumor formation was never observed. We conducted similar in vivo characterization of hIPSA fate following transplantation into the mouse spinal cord immediately following unilateralcervical contusion SCI. Themajority of transplant-derived cells were differentiated GFAP+ astrocytes (H). Control GFP–hIPSAs did not express GLT1, while overexpression resulted in themajority of transplant-derived astrocytes expressing GLT1 (I). Less than 10% of transplant-derived cells continued to proliferate at D2,W2 andW4 (J). Results were expressed asmeans±SEM. ***p b 0.001. n = 3 per group per time point in cell fate analysis.

Fig. 5. GLT1 overexpressing hIPSA transplants reduced lesion size following cervical contusion SCI. At 4 weeks post-injury, we quantified Cresyl-violet stained transverse sections of thecervical spinal cord for the degree of ipsilesional tissue sparing by calculating the percentage of total ipsilateral hemi-cord area comprised of damaged tissue (A). Lesion area (B) and totallesion volume (C) analysis (combined for both white and gray matter) revealed that GLT1–hIPSA transplants significantly reduced lesion size at multiple locations surrounding theepicenter compared to both human fibroblast and control GFP–hIPSA transplant groups. Results were expressed as means ± SEM. #p b 0.05, GLT1–hIPSA group versus GFP–hIPSAgroup only; *p b 0.05, GLT1–hIPSA group versus both control groups. n = 6 per group for lesion area and volume analysis.

487K. Li et al. / Experimental Neurology 271 (2015) 479–492

Fig. 6.GLT1 overexpressing hIPSA astrocyte transplants preserved diaphragm innervation by phrenic motor neurons following cervical contusion SCI. To examine pathological alterationsat the diaphragmNMJ, hemi-diaphragmmuscle ipsilateral to the contusion from the GFP–hFibro (A), GFP–hIPSA and GLT1–hIPSA (B) groupswas examined at 4 weeks post-injury/trans-plantation. Individual NMJs were characterized as: intact (I.) and partially denervated (P.D.). For analysis, the hemi-diaphragmwas divided into three anatomical regions (ventral, medialand dorsal) (C). At the dorsal region of the hemi-diaphragm, the percentage of intact NMJs in the GLT1–hIPSA group was significant greater than both control groups (D). GLT1–hIPSAtransplants significantly reduced the percentage of partially denervated NMJs in the medial and dorsal hemi-diaphragm regions compared to both control groups (E). Results wereexpressed as means ± SEM. *p b 0.05, GLT1–hIPSA group versus both control groups. n = 4–6 per group for NMJ analysis.

488 K. Li et al. / Experimental Neurology 271 (2015) 479–492

(Fig. 6D). GLT1–hIPSA transplants also significantly reduced the per-centage of partially denervated NMJs in the medial and dorsal hemi-diaphragm regions compared to both control groups (Fig. 6E).

3.7. GLT1 overexpressing hIPSA transplants preserved diaphragm functionfollowing cervical contusion SCI

Todetermine the efficacy of preserving PMN-diaphragm innervationwith respect to respiratory impairment, we characterized the in vivofunctional effects of transplants on diaphragmatic function in cervicalcontusion rats. We recorded spontaneous EMG activity, which is indic-ative of PMN activation of diaphragm muscle due to central drive, at4 weeks post-injury/transplantation (Fig. 7A). All groups showed re-duced amplitude in rhythmic inspiratory EMG bursts associated withmuscle contraction compared to uninjured animals (Nicaise et al.,2012). Integrated EMG analysis of this recording shows that the GLT1–hIPSA transplants significantly increased EMG amplitude in the dorsalregion of the hemi-diaphragm compared to both control groups(Fig. 7B), again matching the anatomically-specific spinal cord andNMJ histological results. However, we observed no protective effectsof GLT1–hIPSA transplants at either the medial or ventral regions, andthe control GFP–hIPSA transplants showed no significant effects com-pared to control hFibroblast injection at all hemi-diaphragm locations(Fig. 7B). There were no significant differences in EMG burst frequency(Fig. 7C) or burst duration (Fig. 7D) amongst the three groups.

Following supramaximal phrenic nerve stimulus, we obtained com-pound muscle action potentials (CMAP) recordings from the ipsilateralhemi-diaphragm using a surface electrode (Fig. 7E). In all treatmentgroups, peak CMAP amplitude was significantly reduced compared touninjured laminectomy only rats, whose CMAP amplitudes are approx-imately 7 mV (Nicaise et al., 2013). However, CMAP amplitudes in theGLT1–hIPSAtransplant group were significantly increased compared tothe two control transplantation groups at weeks 2–4 post-injury(Fig. 7F). With the use of the surface electrode, we are recording fromthe entire hemi-diaphragm (or at least a significant portion of the

muscle), yetwe still observed this significant protective effect on overallmuscle function, despite the fact that transplants only reduced centraldegeneration very near to the injury site and correspondingly preservedmorphological innervation only in the dorsal hemi-diaphragm.

4. Discussion

The use of iPS cells as a source of mature cell types for therapeutictransplantation in CNS diseases represents an exciting direction in re-generative medicine. However, to date only a small number of studieshave assessed the long-term fate and therapeutic efficacy of iPS cell-derived transplants in animal models of SCI.

A number of these studies reported significant therapeutic benefitwhen NSCs/NPCs derived from either mouse (Tsuji et al., 2010) orhuman (Fujimoto et al., 2012; Nori et al., 2011; Romanyuk et al.,2014) iPS cells were transplanted into contusion or cavity-type modelsof rodent SCI, aswell as in non-human primatemodels (Kobayashi et al.,2012). Unlike our current work, these studies did not focus on, orachieve, targeted replacement of astrocytes in the injured spinal cord.In many cases, the cells were delivered in a multipotent NSC-like stateand resulted in mixed differentiation into glial phenotypes, includingastrocytes, and various neuronal subtypes. While these studies wereable to achieve some functional benefit, future work may requiremore phenotypically targeted strategies, each of which depends onthe nature of the SCI pathology (e.g. type of injury and anatomical loca-tions affected) and the specific cell lineages being targeted for replace-ment. Nevertheless, these studies were able to nicely show promisingproperties of engrafted cells in the injured spinal cord environment,including synaptic integration into endogenous neuronal circuitry(Fujimoto et al., 2012; Nori et al., 2011). iPS cell-derived NSCs havealso shown therapeutic promise in models of other spinal cord diseasessuch as spinal muscular atrophy (Simone et al., 2014).

A number of these studies with iPS cell transplantation reported alack of beneficial outcomes in SCI models. Pomeshchik et al. (2014)did not observe functional improvement after transplantation of hIPS

Fig. 7.GLT1overexpressing hIPSA transplants preserved diaphragm function following cervical contusion SCI. Spontaneous EMG recordings from ipsilateral hemi-diaphramwere obtainedat 4 weeks post-injury/transplantation (A, upper: raw EMG; lower: integrated EMG). Integrated EMG amplitude (B), burst frequency (C), and burst duration (D)were analyzed. Followingsupramaximal phrenic nerve stimulation, we obtained compound muscle action potential (CMAP) recordings from the ipsilateral hemi-diaphragm using a surface electrode (E). CMAPamplitudes at different time points post-injury were analyzed (F). Results were expressed as means ± SEM. *p b 0.05, **p b 0.01, GLT1–hIPSA group versus both control groups. n = 6per group for EMG and CMAP analysis.

489K. Li et al. / Experimental Neurology 271 (2015) 479–492

cell-derived NPCs in a contusion SCI model. However, they also did notfind long term survival of grafted cells in these mice receiving a tacroli-mus immune suppression regimen, unlike the robust and persistent in-tegration that we observed in the present study using an immunesuppression protocol consisting of both tacrolimus and rapamycin inmice or cyclosporine in rats. In addition to our work, other groupshave reported impressive survival and differentiation of hIPS cells into

mature CNS cell types after injection into adult spinal cord of similarlyimmunosuppressed rodents (Haidet-Phillips et al., 2014; Sareen et al.,2014).

An interesting study from the Horner group (Nutt et al., 2013) re-ported a lack of therapeutic improvement with transplantation of hIPScell-derived NPCs in a SCI model, despite impressive graft integration.However, cells were delivered at a chronic time point, which may

490 K. Li et al. / Experimental Neurology 271 (2015) 479–492

represent an environment less amenable to transplant-induced plastic-ity, while we targeted early neuroprotection in this report.

A recent study from the Steward lab reported that transplantation ofa mixed population of glial and neuronal progenitors into a transectionmodel of SCI resulted in ectopic engraftment of large numbers of graft-derived cells in locations such as the central canal, ventricles and pialsurface of the spinal cord (Steward et al., 2014), providing a note of cau-tion when using transplantation of any class of NSC/NPC in SCI. Thisissue is particularly relevant to strategies employing cells derived frompluripotent sources such as ES and iPS cells given the possibility of in-complete and/or inefficient differentiation (Tsuji et al., 2010). In the cur-rent study and in our previous work (Lepore et al., 2004, 2005, 2006,2008b, 2011b; Lepore and Fischer, 2005; Li et al., 2014), we never ob-served overt tumor formation or extensive migration away from injec-tion sites beyond only a few spinal segments. In the current work, wedid note the presence of a small residual population of proliferatingtransplant-derived cells even out to four weeks post-injection, thoughwe never found any tumor formation. It will be important to assessvery long-term time points post-transplantation in future experimentsto establish the safety of these and similar types of cells before proceed-ing to the clinic. Unlike the Steward paper, we did not systematically as-sess distribution of transplant-derived cells throughout the neuraxis.

Mechanical allodynia (a form of neuropathic pain) was observedwhen mouse iPSAs were transplanted into a contusion SCI model(Hayashi et al., 2011). In addition to this work, other published studieshave similarly reported sensory hypersensitivity in SCI models accom-panying transplantation of progenitor-derived astrocytes (Davieset al., 2008; Hofstetter et al., 2005), possibly due to increased neuronalplasticity that is induced by transplantation of immature astrocyte pop-ulations (Smith et al., 1986). However, in a large body of work, we andothers (Haas et al., 2012; Mitsui et al., 2005; Nutt et al., 2013) have notfound such increased sensitivity, including following hIPSA transplanta-tion (Nutt et al., 2013). The discrepancy amongst these studies may bedue to heterogeneity in the subtypes of astrocytes being injected(Davies et al., 2008, 2011).

A number of practical issues that are beyond the scope of this discus-sionwill need to be addressed beforemoving transplantation of iPS cellsto the clinic in SCI and other diseases of the nervous system. Specificallywith respect to targeting relative early events such as PhMN loss aftercervical SCI, autologous derivation of cells will likely not be relevantgiven that PhMNs are lost within several days post-injury (Nicaiseet al., 2013). Instead, cells to be used for transplantation will likely beobtained from banks of immune/HLA-matched cells (Zimmermannet al., 2012). Given the need to extensively test iPS cell lines prior totransplantation into a patient, as well as the costs and time that willbe required for generating cells for each individual patient, this ap-proach may actually be practically preferable to autologous derivation(Taylor et al., 2011). As human stem cell lines have shown donor vari-ability in SCI models (Neuhuber et al., 2005), future studies will needto investigate in vivo properties and therapeutic efficacy of human iPScells derived frommultiple donors in an attempt to move this approachtoward clinical translation.

Similar to our previous work using transplantation of astrocytes de-rived from rodent glial progenitors (Li et al., 2014), we find that GLT1-overexpresing hIPSAs promote significant preservation of diaphragmfunction and diaphragm innervation by PhMNs. In both studies, controlunmodified transplant-derived astrocytes expressed relatively lowerlevels of GLT1 in the injured spinal cord, suggesting that the cells re-spond to the injured environment in a similarmanner as host astrocytesthat show extensive transporter downregulation. Interestingly, theunmodified hIPSA transplants, despite excellent survival and efficientdifferentiation, did not promote therapeutic benefit with respect to pro-tection of diaphragmatic respiratory circuitry. These findings suggestthat astrocyte replacement alone may insufficient when targeting cer-tain pathological mechanisms (e.g. excitotoxocity) but that functionalmaturation of these astrocytes is necessary, which is not surprising

given the diverse, complex and integral roles that astrocytes play in in-tact CNS function (Pekny and Nilsson, 2005).

We havemade interesting observations over the course of a numberof studies with respect to therapeutically targeting GLT1 following SCI.We have consistently observed significant GLT1 downregulation in en-dogenous reactive astrocyte populations in both contusion and crush, aswell as both cervical and thoracic, models of SCI (Lepore et al., 2011a,2011c; Li et al., 2015; Putatunda et al., 2014; Watson et al., 2014).When we selectively increased GLT1 expression in these endogenousastrocytes in the unilateral cervical contusionmodel using anAAV8 vec-tor, we paradoxically found that secondary degeneration of PhMNs anddiaphragm denervation were worsened (Li et al., 2015). This effect wasdue to compromise in the protective glial scar-forming properties ofendogenous astrocytes, which resulted in unexpected expansion ofthe lesion. In the current study with hIPSAs and in our previous workwith rodent-derived glial progenitors (Li et al., 2014), we found that de-livery of an exogenous source of astrocytes that expresses high levels offunctional GLT1 via transplantation (in the exact same cervical contu-sionmodel) results in significant preservation of PhMNs and diaphragmfunction. These findings, as well as other studies that tested the effectsof pharmacologically elevating (Olsen et al., 2010) or genetically reduc-ing (Lepore et al., 2011c) GLT1 in SCI, demonstrate that targetingGLT1 isa promising and powerful therapeutic strategy in SCI for targetingneuroprotection and possibly other outcomes of SCI such as neuronalhyperexcitability.

Despite the impressive therapeutic effect achieved in the presentstudy, the degree of PhMN protection and diaphragm function preser-vation was only partial. In future work, we will need to optimizeneuroprotective strategies such as hIPSA transplantation to enhancetherapeutic effects, as well as combine these neuroprotective ap-proaches with interventions aimed at promoting plasticity, axonal re-growth and targeted reconnection of the rVRG-PhMN-diaphragmcircuit (Alilain et al., 2011). Preserving neural control of diaphragmfunction involves targeting a complex circuitry that extends beyondjust protecting PhMNs (Lane et al., 2009). We focused on preservationof PhMNs centrally in the cervical spinal cord and NMJ innervation pe-ripherally in the diaphragm. Nevertheless, our hIPSA intervention mayhave also exerted beneficial effects via protection of respiratory inter-neuron populations of the cervical spinal cord and/or descendingbulbospinal input to PhMNs from the rVRG. hIPSA transplants mayhave also resulted in beneficial effects by promoting regrowth/regener-ation and/or sprouting of rVRG axons and interneurons, which is possi-ble given the growth-promoting properties of astrocyte transplantsafter SCI (Davies et al., 2006, 2008, 2011; Haas et al., 2012). However,we only observed therapeutic effects on diaphragm innervation andfunction with GLT1 overexpressing hIPSAs (but not with controlunmodified hIPSAs), suggesting that neuroprotection mediated by in-creased GLT1 levels and consequent reduction in excitotoxicity wasthe likelymechanism, even if transplants also promoted some regrowthof respiratory axon populations. We also did not observe differencesamongst groups in plasticity at the diaphragm NMJ such as sproutingor reinnervation, further supporting central neuroprotection as the re-sponsible mechanism of therapeutic action.

In conclusion, we report exciting and novel results showing thattargeted replacement of astrocyte GLT1 following cervical SCI usinghIPSA transplantation significantly preserves diaphragmatic respiratoryfunction. These findings are important for a number of reasons. Wedemonstrate the therapeutic efficacy and safety of hiPS transplantationin SCI, aswell as the benefit of specifically addressing astrocyte dysfunc-tion using this clinically-relevant source of cells. We also show mecha-nistically that targeting GLT1 using an astrocyte transplant-basedapproach has profound effects on functional and histopatholoigcal out-comes after SCI. Furthermore,we conducted these studies in a clinically-relevant SCI paradigm that models a large proportion of human diseasecases. Excitingly, we find that this intervention results in therapeuticbenefit on respiratory function, which has important implications for

491K. Li et al. / Experimental Neurology 271 (2015) 479–492

SCI patients. Collectively, these studies lay the foundation for translatingiPS cell transplantation to the treatment of SCI.

Acknowledgments, contributions and funding

KL: Conception and design, collection and assembly of data, dataanalysis and interpretation, manuscript writing. EJ, TJH, SS, MCW: Col-lection and assembly of data, data analysis and interpretation. JPR,NJM: Provision of study materials. ACL: Conception and design, collec-tion and assembly of data, data analysis and interpretation, manuscriptwriting, final approval of manuscript. This work was supported by theCraig H. Neilsen Foundation (grant #190140 to A.C.L.) and the NINDS(grant #1R01NS079702 to A.C.L.).

References

Aguilar, R.M., Steward, O., 2010. A bilateral cervical contusion injury model in mice:assessment of gripping strength as a measure of forelimb motor function. Exp.Neurol. 221, 38–53.

Alilain, W.J., Horn, K.P., Hu, H., Dick, T.E., Silver, J., 2011. Functional regeneration of respi-ratory pathways after spinal cord injury. Nature 475, 196–200.

Awad, B.I., Warren, P.M., Steinmetz, M.P., Alilain,W.J., 2013. The role of the crossed phren-ic pathway after cervical contusion injury and a new model to evaluate therapeuticinterventions. Exp. Neurol. 248, 398–405.

Das, A.K., Pal, R., 2010. Induced pluripotent stem cells (iPSCs): the emergence of a newchampion in stem cell technology-driven biomedical applications. J. Tissue Eng.Regen. Med. 4, 413–421.

Davies, J.E., Huang, C., Proschel, C., Noble, M., Mayer-Proschel, M., Davies, S.J., 2006. Astro-cytes derived from glial-restricted precursors promote spinal cord repair. J. Biol. 5, 7.

Davies, J.E., Proschel, C., Zhang, N., Noble, M., Mayer-Proschel, M., Davies, S.J., 2008.Transplanted astrocytes derived from BMP- or CNTF-treated glial-restricted precur-sors have opposite effects on recovery and allodynia after spinal cord injury. J. Biol.7, 24.

Davies, S.J., Shih, C.H., Noble, M., Mayer-Proschel, M., Davies, J.E., Proschel, C., 2011. Trans-plantation of specific human astrocytes promotes functional recovery after spinalcord injury. PLoS One 6, e17328.

Dowd, L.A., Robinson, M.B., 1996. Rapid stimulation of EAAC1-mediated Na+-dependentL-glutamate transport activity in C6 glioma cells by phorbol ester. J. Neurochem. 67,508–516.

Fujimoto, Y., Abematsu, M., Falk, A., Tsujimura, K., Sanosaka, T., Juliandi, B., Semi, K.,Namihira, M., Komiya, S., Smith, A., Nakashima, K., 2012. Treatment of a mousemodel of spinal cord injury by transplantation of human induced pluripotent stemcell-derived long-term self-renewing neuroepithelial-like stem cells. Stem Cells 30,1163–1173.

Gage, F.H., 2000. Mammalian neural stem cells. Science 287, 1433–1438.Gensel, J.C., Tovar, C.A., Hamers, F.P., Deibert, R.J., Beattie, M.S., Bresnahan, J.C., 2006. Be-

havioral and histological characterization of unilateral cervical spinal cord contusioninjury in rats. J. Neurotrauma 23, 36–54.

Gwak, Y.S., Kang, J., Unabia, G.C., Hulsebosch, C.E., 2012. Spatial and temporal activation ofspinal glial cells: role of gliopathy in central neuropathic pain following spinal cordinjury in rats. Exp. Neurol. 234, 362–372.

Haas, C., Neuhuber, B., Yamagami, T., Rao, M., Fischer, I., 2012. Phenotypic analysis ofastrocytes derived from glial restricted precursors and their impact on axon regener-ation. Exp. Neurol. 233, 717–732.

Haidet-Phillips, A.M., Roybon, L., Gross, S.K., Tuteja, A., Donnelly, C.J., Richard, J.P., Ko, M.,Sherman, A., Eggan, K., Henderson, C.E., Maragakis, N.J., 2014. Gene profiling ofhuman induced pluripotent stem cell-derived astrocyte progenitors following spinalcord engraftment. Stem Cells Transl. Med. 3, 575–585.

Hayashi, K., Hashimoto, M., Koda, M., Naito, A.T., Murata, A., Okawa, A., Takahashi, K.,Yamazaki, M., 2011. Increase of sensitivity to mechanical stimulus after transplanta-tion of murine induced pluripotent stem cell-derived astrocytes in a rat spinal cordinjury model. J. Neurosurg. Spine 15, 582–593.

Hofstetter, C.P., Holmstrom, N.A., Lilja, J.A., Schweinhardt, P., Hao, J., Spenger, C.,Wiesenfeld-Hallin, Z., Kurpad, S.N., Frisen, J., Olson, L., 2005. Allodynia limits theusefulness of intraspinal neural stem cell grafts; directed differentiation improvesoutcome. Nat. Neurosci. 8, 346–353.

Hulsebosch, C.E., 2008. Gliopathy ensures persistent inflammation and chronic pain afterspinal cord injury. Exp. Neurol. 214, 6–9.

Kiskinis, E., Eggan, K., 2010. Progress toward the clinical application of patient-specificpluripotent stem cells. J. Clin. Invest. 120, 51–59.

Kobayashi, Y., Okada, Y., Itakura, G., Iwai, H., Nishimura, S., Yasuda, A., Nori, S., Hikishima,K., Konomi, T., Fujiyoshi, K., Tsuji, O., Toyama, Y., Yamanaka, S., Nakamura, M., Okano,H., 2012. Pre-evaluated safe human iPSC-derived neural stem cells promote function-al recovery after spinal cord injury in common marmoset without tumorigenicity.PLoS One 7, e52787.

Lane, M.A., Fuller, D.D., White, T.E., Reier, P.J., 2008. Respiratory neuroplasticity and cervi-cal spinal cord injury: translational perspectives. Trends Neurosci. 31, 538–547.

Lane, M.A., Lee, K.Z., Fuller, D.D., Reier, P.J., 2009. Spinal circuitry and respiratory recoveryfollowing spinal cord injury. Respir. Physiol. Neurobiol. 169, 123–132.

Lane, M.A., Lee, K.Z., Salazar, K., O'Steen, B.E., Bloom, D.C., Fuller, D.D., Reier, P.J., 2012. Re-spiratory function following bilateral mid-cervical contusion injury in the adult rat.Exp. Neurol. 235, 197–210.

Laskowski, M.B., Sanes, J.R., 1987. Topographic mapping of motor pools onto skeletalmuscles. J. Neurosci. 7, 252–260.

Lee, J.H., Tigchelaar, S., Liu, J., Stammers, A.M., Streijger, F., Tetzlaff, W., Kwon, B.K., 2010.Lack of neuroprotective effects of simvastatin and minocycline in a model of cervicalspinal cord injury. Exp. Neurol. 225, 219–230.

Lepore, A.C., Fischer, I., 2005. Lineage-restricted neural precursors survive, migrate, anddifferentiate following transplantation into the injured adult spinal cord. Exp. Neurol.194, 230–242.

Lepore, A.C., Maragakis, N.J., 2011. Stem cell transplantation for spinal cord neurodegen-eration. Methods Mol. Biol. 793, 479–493.

Lepore, A.C., Han, S.S., Tyler-Polsz, C., Cai, J., Rao, M.S., Fischer, I., 2004. Differential fate ofmultipotent and lineage-restricted neural precursors following transplantation intothe adult CNS. Neuron Glia Biol. 1, 113–126.

Lepore, A.C., Bakshi, A., Swanger, S.A., Rao, M.S., Fischer, I., 2005. Neural precursor cells canbe delivered into the injured cervical spinal cord by intrathecal injection at the lum-bar cord. Brain Res. 1045, 206–216.

Lepore, A.C., Neuhuber, B., Connors, T.M., Han, S.S., Liu, Y., Daniels, M.P., Rao, M.S., Fischer,I., 2006. Long-term fate of neural precursor cells following transplantation into devel-oping and adult CNS. Neuroscience 139, 513–530.

Lepore, A.C., Dejea, C., Carmen, J., Rauck, B., Kerr, D.A., Sofroniew, M.V., Maragakis, N.J.,2008a. Selective ablation of proliferating astrocytes does not affect disease outcomein either acute or chronic models of motor neuron degeneration. Exp. Neurol. 211,423–432.

Lepore, A.C., Rauck, B., Dejea, C., Pardo, A.C., Rao, M.S., Rothstein, J.D., Maragakis, N.J.,2008b. Focal transplantation-based astrocyte replacement is neuroprotective in amodel of motor neuron disease. Nat. Neurosci. 11, 1294–1301.

Lepore, A.C., O'Donnell, J., Bonner, J.F., Paul, C., Miller, M.E., Rauck, B., Kushner, R.A.,Rothstein, J.D., Fischer, I., Maragakis, N.J., 2011a. Spatial and temporal changes in pro-moter activity of the astrocyte glutamate transporter GLT1 following traumatic spinalcord injury. J. Neurosci. Res. 89, 1001–1017.

Lepore, A.C., O'Donnell, J., Kim, A.S., Williams, T., Tuteja, A., Rao, M.S., Kelley, L.L.,Campanelli, J.T., Maragakis, N.J., 2011b. Human glial-restricted progenitor trans-plantation into cervical spinal cord of the SOD1G93A mouse model of ALS. PLoSOne 6.

Lepore, A.C., O'Donnell, J., Kim, A.S., Yang, E.J., Tuteja, A., Haidet-Phillips, A., O'Banion, C.P.,Maragakis, N.J., 2011c. Reduction in expression of the astrocyte glutamate transport-er, GLT1, worsens functional and histological outcomes following traumatic spinalcord injury. Glia 59, 1996–2005.

Li, K., Nicaise, C., Sannie, D., Hala, T.J., Javed, E., Parker, J.L., Putatunda, R., Regan, K.A., Suain,V., Brion, J.P., Rhoderick, F., Wright, M.C., Poulsen, D.J., Lepore, A.C., 2014. Overexpres-sion of the astrocyte glutamate transporter GLT1 exacerbates phrenic motor neurondegeneration, diaphragm compromise, and forelimb motor dysfunction followingcervical contusion spinal cord injury. J. Neurosci. 34, 7622–7638.

Li, K., Javed, E., Hala, T.J., Sannie, D., Regan, K.A., Maragakis, N.J., Wright, M.C., Poulsen, D.J.,Lepore, A.C., 2015. Transplantation of glial progenitors that overexpress glutamatetransporter GLT1 preserves diaphragm function following cervical SCI. Mol. Ther.23, 533–548.

Liu, D., Thangnipon, W., McAdoo, D.J., 1991. Excitatory amino acids rise to toxic levelsupon impact injury to the rat spinal cord. Brain Res. 547, 344–348.

Maragakis, N.J., Rothstein, J.D., 2004. Glutamate transporters: animalmodels to neurologicdisease. Neurobiol. Dis. 15, 461–473.

Maragakis, N.J., Rothstein, J.D., 2006. Mechanisms of disease: astrocytes in neurodegener-ative disease. Nat. Clin. Pract. Neurol. 2, 679–689.

McDonald, J.W., Becker, D., 2003. Spinal cord injury: promising interventions and realisticgoals. Am. J. Phys. Med. Rehabil. 82, S38–S49.

Mitsui, T., Shumsky, J.S., Lepore, A.C., Murray, M., Fischer, I., 2005. Transplantation of neu-ronal and glial restricted precursors into contused spinal cord improves bladder andmotor functions, decreases thermal hypersensitivity, andmodifies intraspinal circuit-ry. J. Neurosci. 25, 9624–9636.

Neuhuber, B., Timothy Himes, B., Shumsky, J.S., Gallo, G., Fischer, I., 2005. Axon growthand recovery of function supported by human bone marrow stromal cells in the in-jured spinal cord exhibit donor variations. Brain Res. 1035, 73–85.

Nicaise, C., Hala, T.J., Frank, D.M., Parker, J.L., Authelet, M., Leroy, K., Brion, J.P., Wright,M.C., Lepore, A.C., 2012. Phrenic motor neuron degeneration compromises phrenicaxonal circuitry and diaphragm activity in a unilateral cervical contusion model ofspinal cord injury. Exp. Neurol. 235, 539–552.

Nicaise, C., Frank, D.M., Hala, T.J., Authelet, M., Pochet, R., Adriaens, D., Brion, J.P., Wright, M.C.,Lepore, A.C., 2013. Early phrenic motor neuron loss and transient respiratory abnormal-ities after unilateral cervical spinal cord contusion. J. Neurotrauma 30, 1092–1099.

Nori, S., Okada, Y., Yasuda, A., Tsuji, O., Takahashi, Y., Kobayashi, Y., Fujiyoshi, K., Koike, M.,Uchiyama, Y., Ikeda, E., Toyama, Y., Yamanaka, S., Nakamura, M., Okano, H., 2011.Grafted human-induced pluripotent stem-cell-derived neurospheres promotemotor functional recovery after spinal cord injury in mice. Proc. Natl. Acad. Sci. U. S.A. 108, 16825–16830.

Nutt, S.E., Chang, E.A., Suhr, S.T., Schlosser, L.O., Mondello, S.E., Moritz, C.T., Cibelli, J.B.,Horner, P.J., 2013. Caudalized human iPSC-derived neural progenitor cells produceneurons and glia but fail to restore function in an early chronic spinal cord injurymodel. Exp. Neurol. 248, 491–503.

Olsen, M.L., Campbell, S.C., McFerrin, M.B., Floyd, C.L., Sontheimer, H., 2010. Spinal cordinjury causes a wide-spread, persistent loss of Kir4.1 and glutamate transporter 1:benefit of 17 beta-oestradiol treatment. Brain 133, 1013–1025.

Panter, S.S., Yum, S.W., Faden, A.I., 1990. Alteration in extracellular amino acids aftertraumatic spinal cord injury. Ann. Neurol. 27, 96–99.

492 K. Li et al. / Experimental Neurology 271 (2015) 479–492

Park, E., Velumian, A.A., Fehlings, M.G., 2004. The role of excitotoxicity in secondarymechanisms of spinal cord injury: a review with an emphasis on the implicationsfor white matter degeneration. J. Neurotrauma 21, 754–774.

Pekny, M., Nilsson, M., 2005. Astrocyte activation and reactive gliosis. Glia 50, 427–434.Perego, C., Vanoni, C., Bossi, M., Massari, S., Basudev, H., Longhi, R., Pietrini, G., 2000. The

GLT-1 and GLAST glutamate transporters are expressed on morphologically distinctastrocytes and regulated by neuronal activity in primary hippocampal cocultures.J. Neurochem. 75, 1076–1084.

Pomeshchik, Y., Puttonen, K.A., Kidin, I., Ruponen, M., Lehtonen, S., Malm, T., Akesson, E.,Hovatta, O., Koistinaho, J., 2014. Transplanted human iPSC-derived neural progenitorcells do not promote functional recovery of pharmacologically immunosuppressedmice with contusion spinal cord injury. Cell Transplant.

Putatunda, R., Hala, T.J., Chin, J., Lepore, A.C., 2014. Chronic at-level thermal hyperalgesiafollowing rat cervical contusion spinal cord injury is accompanied by neuronal andastrocyte activation and loss of the astrocyte glutamate transporter, GLT1, in superfi-cial dorsal horn. Brain Res. 18, 64–79.

Romanyuk, N., Amemori, T., Turnovcova, K., Prochazka, P., Onteniente, B., Sykova, E.,Jendelova, P., 2014. Beneficial effect of human induced pluripotent stem cell-derived neural precursors in spinal cord injury repair. Cell Transplant.

Salewski, R.P., Eftekharpour, E., Fehlings, M.G., 2010. Are induced pluripotent stem cellsthe future of cell-based regenerative therapies for spinal cord injury? J. Cell. Physiol.222, 515–521.

Sandrow, H.R., Shumsky, J.S., Amin, A., Houle, J.D., 2008. Aspiration of a cervical spinalcontusion injury in preparation for delayed peripheral nerve grafting does not impairforelimb behavior or axon regeneration. Exp. Neurol. 210, 489–500.

Sandrow-Feinberg, H.R., Izzi, J., Shumsky, J.S., Zhukareva, V., Houle, J.D., 2009. Forced ex-ercise as a rehabilitation strategy after unilateral cervical spinal cord contusion injury.J. Neurotrauma 26, 721–731.

Sandrow-Feinberg, H.R., Zhukareva, V., Santi, L., Miller, K., Shumsky, J.S., Baker, D.P., Houle,J.D., 2010. PEGylated interferon-betamodulates the acute inflammatory response andrecovery when combined with forced exercise following cervical spinal contusion in-jury. Exp. Neurol. 223, 439–451.

Sareen, D., Gowing, G., Sahabian, A., Staggenborg, K., Paradis, R., Avalos, P., Latter, J.,Ornelas, L., Garcia, L., Svendsen, C.N., 2014. Human induced pluripotent stem cellsare a novel source of neural progenitor cells (iNPCs) that migrate and integrate inthe rodent spinal cord. J. Comp. Neurol. 522, 2707–2728.

Shanmuganathan, K., Gullapalli, R.P., Zhuo, J., Mirvis, S.E., 2008. Diffusion tensor MRimaging in cervical spine trauma. AJNR Am. J. Neuroradiol. 29, 655–659.

Simone, C., Nizzardo, M., Rizzo, F., Ruggieri, M., Riboldi, G., Salani, S., Bucchia, M., Bresolin,N., Comi, G.P., Corti, S., 2014. iPSC-derived neural stem cells act via kinase inhibitionto exert neuroprotective effects in spinal muscular atrophy with respiratory distresstype 1. Stem Cell Rep. 3, 297–311.

Smith, G.M., Miller, R.H., Silver, J., 1986. Changing role of forebrain astrocytes during de-velopment, regenerative failure, and induced regeneration upon transplantation.J. Comp. Neurol. 251, 23–43.

Stamegna, J.C., Felix, M.S., Roux-Peyronnet, J., Rossi, V., Feron, F., Gauthier, P., Matarazzo,V., 2011. Nasal OEC transplantation promotes respiratory recovery in a subchronicrat model of cervical spinal cord contusion. Exp. Neurol. 229, 120–131.

Steward, O., Sharp, K.G., Yee, K.M., Hatch, M.N., Bonner, J.F., 2014. Characterization ofectopic colonies that form in widespread areas of the nervous system with neuralstem cell transplants into the site of a severe spinal cord injury. J. Neurosci. 34,14013–14021.

Strakowski, J.A., Pease, W.S., Johnson, E.W., 2007. Phrenic nerve stimulation in the evalu-ation of ventilator-dependent individuals with C4- and C5-level spinal cord injury.Am. J. Phys. Med. Rehabil. 86, 153–157.

Stys, P.K., 2004. White matter injury mechanisms. Curr. Mol. Med. 4, 113–130.Takahashi, K., Okita, K., Nakagawa, M., Yamanaka, S., 2007a. Induction of pluripotent stem

cells from fibroblast cultures. Nat. Protoc. 2, 3081–3089.Takahashi, K., Tanabe, K., Ohnuki, M., Narita, M., Ichisaka, T., Tomoda, K., Yamanaka, S.,

2007b. Induction of pluripotent stem cells from adult human fibroblasts by definedfactors. Cell 131, 861–872.

Taylor, C.J., Bolton, E.M., Bradley, J.A., 2011. Immunological considerations for embryonicand induced pluripotent stem cell banking. Philos. Trans. R. Soc. Lond. B Biol. Sci. 366,2312–2322.

Tsuji, O., Miura, K., Okada, Y., Fujiyoshi, K., Mukaino, M., Nagoshi, N., Kitamura, K.,Kumagai, G., Nishino, M., Tomisato, S., Higashi, H., Nagai, T., Katoh, H., Kohda,K., Matsuzaki, Y., Yuzaki, M., Ikeda, E., Toyama, Y., Nakamura, M., Yamanaka, S.,Okano, H., 2010. Therapeutic potential of appropriately evaluated safe-inducedpluripotent stem cells for spinal cord injury. Proc. Natl. Acad. Sci. U. S. A. 107,12704–12709.

Watson, J.L., Hala, T.J., Putatunda, R., Sannie, D., Lepore, A.C., 2014. Persistent at-level ther-mal hyperalgesia and tactile allodynia accompany chronic neuronal and astrocyteactivation in superficial dorsal horn following mouse cervical contusion spinal cordinjury. PLoS One 9, e109099.

Wright, M.C., Son, Y.J., 2007. Ciliary neurotrophic factor is not required for terminalsprouting and compensatory reinnervation of neuromuscular synapses: re-evaluation of CNTF null mice. Exp. Neurol. 205, 437–448.

Wright, M.C., Cho,W.J., Son, Y.J., 2007. Distinct patterns ofmotor nerve terminal sproutinginduced by ciliary neurotrophic factor vs. botulinum toxin. J. Comp. Neurol. 504,1–16.

Wright, M.C., Potluri, S., Wang, X., Dentcheva, E., Gautam, D., Tessler, A., Wess, J., Rich,M.M., Son, Y.J., 2009. Distinct muscarinic acetylcholine receptor subtypes contributeto stability and growth, but not compensatory plasticity, of neuromuscular synapses.J. Neurosci. 29, 14942–14955.

Xu, G.Y., Hughes, M.G., Ye, Z., Hulsebosch, C.E., McAdoo, D.J., 2004. Concentrations of glu-tamate released following spinal cord injury kill oligodendrocytes in the spinal cord.Exp. Neurol. 187, 329–336.

Xu, G.Y., Hughes, M.G., Zhang, L., Cain, L., McAdoo, D.J., 2005. Administration of glutamateinto the spinal cord at extracellular concentrations reached post-injury causes func-tional impairments. Neurosci. Lett. 384, 271–276.

Zimmer, M.B., Nantwi, K., Goshgarian, H.G., 2007. Effect of spinal cord injury on the respi-ratory system: basic research and current clinical treatment options. J. Spinal CordMed. 30, 319–330.

Zimmermann, A., Preynat-Seauve, O., Tiercy, J.M., Krause, K.H., Villard, J., 2012. Haplotype-based banking of human pluripotent stem cells for transplantation: potential andlimitations. Stem Cells Dev. 21, 2364–2373.